NEW LICENSE APPLICATION BOARD OF MASSAGE THERAPY · 11/06/2019  · MT – Massage Therapist by Examination $262.00 MT – Massage Therapist by Endorsement $262.00 Duplicate Licenses

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF HEALTH – HEALTH PROFESSIONAL LICENSING ADMINISTRATION

NEW LICENSE APPLICATION

BOARD OF MASSAGE THERAPY

Please read instructions before completing this form. If you have any questions, call HPLA Customer Service at 1-877-274-2174, Monday through

Friday, 8:30AM to 4:30PM EST. A charge of $65.00 will be imposed for dishonored checks (Public Law 89-208)

SECTION 1. REQUESTED LICENSE TYPE/FEES (includes non-refundable application fee – see instructions)

MT – Massage Therapist by Examination $262.00

MT – Massage Therapist by Endorsement $262.00

Duplicate Licenses (limit 5) X $34.00 = $ .00

Make check or money order payable to DC Treasurer

MAIL TO:

DC Board of Massage Therapy P.O. Box 37802 Washington, D.C. 20013

Total Enclosed $ .00 Staff

$ .00

SECTION 2. APPLICANT NAME/DEMOGRAPHIC INFORMATION

Enter your name exactly as it should appear on the license. If your name has changed at any point since you first attended college or university, please complete Section 4 on page 2. You must also provide a copy of a legal name change document for EACH time that it has changed. Acceptable documents for individuals are marriage certificates, divorce decrees, or court orders.

FIRST NAME MI LAST NAME SUFFIX

(Jr, Sr, etc.)

M M D D Y Y Y Y

SOCIAL SECURITY NUMBER

If applicant does not provide a social security number, a sworn affidavit is required.

DATE OF BIRTH

PLACE OF BIRTH

Provide City and State for US birthplace or Country for foreign place of birth.

SECTION 3. SUPPORTING DOCUMENTS REQUIRED

Male Female GENDER

Please check the correct box.

Please indicate the supporting documents you have included with this package or requested to be sent to the Board of Massage Therapy. Keep a photocopy of all supporting documents for your records.

HPLA

ONLY

Two recent and identical passport-type photos of the applicant’s face (approx. 2”X2”) with applicant’s name printed on A. the back. The photos must be original photos and cannot be computer-generated copies or paper copies.

B. Official transcript (with seal) from EACH approved or accredited institution. May be sent directly from the school, but it is preferred that it accompany the application in a sealed envelope.

National Certification Examination for Therapeutic Massage and Bodywork, Inc. (NCETMB) score report or another C. examination’s results certified by the National commission of Certifying Agencies (NCCA) and approved at the

discretion of the Board.

YES NO

YES NO

YES NO

D. If you are or have ever been licensed in another state/jurisdiction: Verification of State Licensure from EACH jurisdiction. YES NO

E. Copies of legal documents supporting all name changes. YES NO

If educated in foreign country and the documents necessary to evaluate applicant’s practical training and education are

F. not in English: Applicant shall arrange for translation of said documents into English.

YES NO

Not applicable. YES NO

G.

H. Not applicable. YES NO

Updated:6-11-19

FIRST NAME MI LAST NAME SUFFIX

Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr, Sr, etc

FIRST NAME MI LAST NAME SUFFIX

Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr, Sr, etc

FIRST NAME MI LAST NAME SUFFIX

Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate (Jr, Sr, etc

Section 4. PREVIOUS NAMES

If your name has changed at any point since you first attended college or university, you must provide a copy of a legal name change document for EACH time that it has changed. Acceptable documents for individuals are marriage certificates, divorce decrees, or court orders.

Changed to current name by: Marriage Divorce Court Order Spouse Death Certificate

.)

.)

.)

FIRST NAME MI LAST NAME SUFFIX

(Jr, Sr, etc.)

Section 5A. HOME ADDRESS

Even if you have a PO Box, a street address should also be provided, if applicable.

APARTMENT SUITE FLOOR PO BOX NUMBER

HOME STREET ADDRESS 1 (If applicable, use this line for additional building information. Otherwise, use this line to indicate STREET NUMBER and STREET NAME)

HOME STREET ADDRESS 2 (If additional space is needed, use this line to indicate STREET NUMBER and STREET NAME)

CITY

STATE ZIP CODE + 4

HOME PHONE NUMBER HOME FAX NUMBER

Section 5B. BUSINESS ADDRESS

Please note: This information will be made available to the public.

COMPANY NAME

APARTMENT SUITE FLOOR PO BOX NUMBER

BUSINESS STREET ADDRESS 1 (If applicable, use this line for additional building information. Otherwise use this line to indicate STREET NUMBER and STREET NAME)

BUSINESS STREET ADDRESS 2 (If additional space is needed, use this line to indicate STREET NUMBER and STREET NAME)

CITY

STATE ZIP CODE + 4

BUSINESS PHONE NUMBER BUSINESS FAX NUMBER

Section 5C. PREFERRED MAILING ADDRESS

Indicate your preferred mailing address by placing an “X” in the appropriate box. This will be the address to which all future licensing documents will be mailed. The address that will appear on your license will be your business address.

HOME BUSINESS

EMAIL ADDRESS (REQUIRED):

Updated:6-11-19

Section 6A. PROFESSIONAL SCHOOLS ATTENDED

List all professional schools that you have attended, in reverse chronological order, beginning with the most recent at the top.

School Name, City, State, Country

Number of Hours

Completed

Date of

Graduation

Type of

Degree/Certificate

Section 6B. POSTGRADUATE EXPERIENCE

List all experience since graduation from school, in reverse chronological order, beginning with the most recent.

Organization/Institution Location

Start

Date

End

Date

Type of Position

(Use Key Below)*

Full

Time

Part

Time

* TYPE OF POSITION KEY

A. Employment

B. Internship

C. Private Practice

D. Clinical Rotations

E. Other (specify on separate sheet of paper)

Section 6C. PROFESSIONAL LICENSES IN OTHER STATES/JURISDICTIONS

List all states and jurisdictions in which you have ever held a license. Provide letters of verification from original and current jurisdictions (if different).

Jurisdiction

Date License Was

First Obtained

License Number

Updated:6-11-19

SECTION 7. QUESTIONS – Applicants MUST answer all of the following questions.

Please answer all of the following questions by placing an “X” in the appropriate boxes. If you answer “Yes” to questions B through J below, you must provide full information and complete details on a separate sheet of paper, including copies of relevant court documents, and attach to this application.

Clean Hands Before Receiving a License or Permit Act of 1996 Certification Form Requirement.

Please read the information below carefully before responding to this yes or no question, as any false information provided requires that the Department of Health proceed immediately to revoke your License or Permit for which you are now applying, and fine you one thousand dollars ($1,000.00), pursuant to D.C. Official Code § 47-2864 (2001).

IF YOU ANSWER “YES” TO THIS QUESTION, PLEASE SUBMIT PROOF OF THE ARRANGEMENTS YOU HAVE MADE TO PAY THE OUTSTANDING DEBT. IF YOU DO NOT HAVE AN APPROVED PAYMENT SCHEDULE TO PAY THE AMOUNT YOU OWE OR IF NO APPEAL IS PENDING, THE LAW REQUIRES THAT YOUR NEW LICENSE APPLICATION BE DENIED.

As of this date, do you owe more than one hundred dollars ($100.00) to the District of Columbia Government as a result of any of the following: Yes No

A. 1. Fines, penalties, or interest assessed pursuant to D.C. Official Code Title 8, Chapter 8 (Litter Control Administrative Act of 1985);

2. Fines or interest assessed pursuant to D.C. Official Code Title 8, Chapter 9 (Illegal Dumping Enforcement Act of 1994);

3. Fines, penalties, or interest assessed pursuant to D.C. Official Code Title 2, Chapter 18 (Civil Infractions Act of 1985);

4. Past due taxes;

5. Past due District of Columbia Water and Sewer Authority service fees; or

6. Fines or penalties assessed pursuant to D.C. Official Code Title 50, Chapter 23 (Traffic Adjudication)?

The information presented above is in compliance with the requirement to submit with your application for licensure or permit under the

Clean Hands Before Receiving a License or Permit Act of 1996, effective May 11, 1996 (D.C. Law 11-118, D.C. Code §47-2861 et seq.).

HPLA ONLY

YES NO

B. Have you ever been convicted or investigated of a crime or misdemeanor (other than minor traffic violations) not previously reported to the Board?

C. Are you now or have you ever been licensed in DC or any other state/jurisdiction? (If "Yes," be sure to complete Section 6C of this form.)

YES NO

YES NO

D. Have you ever been party to a malpractice action or had a malpractice action brought against you?

E. Have you ever voluntarily surrendered a license after formal charges have been filed against you or while under investigation?

YES NO

YES NO

F. Have you ever been terminated from or resigned from a clinical or professional training program?

YES NO

G. Do you have a physical or medical condition that currently impairs your ability to practice your profession? YES NO

H. Has the use of drugs and/or alcohol resulted in an impairment of your ability to practice your profession? YES NO

(1) Have you withdrawn an application (in D.C. or any other state/jurisdiction) to practice your profession? (2) Has any authority or peer review board taken adverse action against your license or privileges? (3) Are you currently under

I. investigation or were you investigated by any authority or peer review board for any violation of state, federal, or local law? (4) Has any authority or peer review board informed you of any pending charges(s) or investigation not previously

reported to this Board?

YES NO

J. Have you ever been terminated or asked to resign from employment since obtaining your (professional) license?

YES NO

I hereby attest that the information given in this application, including all writings and exhibits attached hereto, is true and complete to the best of my knowledge. I understand that the making of a false statement on this application, including all writings and exhibits attached hereto, is punishable by criminal penalties.

HPLA ONLY

LICENSEE SIGNATURE NAME (Please Print) DATE

REPORT FRAUD, WASTE, AND ABUSE: To report fraud, waste, or abuse within the District government, contact the DC Office of the

Inspector General’s hotline by phone at 1-800-521-1639 (toll free) or 202-724-TIPS (8477), by email at [email protected], or by TTY at

711. For additional information, visit the Office of the Inspector General’s website at oig.dc.gov.

Updated:6-11-19